Physical Therapist's Guide to Medial Apophysitis (Pitcher's Elbow)
Medial apophysitis, or pitcher's elbow, is a condition that occurs as a result of an injury or irritation to the inside of the elbow, commonly affecting young athletes. It is often classified as an "overuse syndrome" in baseball or softball players in the developmental stages of rapid growth (approximately 11 to 15 years of age). Pitcher’s elbow can be identified and effectively treated by a physical therapist.
What is Medial Apophysitis?
Pitcher's elbow occurs when there is irritation to the inside portion of the elbow joint where the arm bone (humerus) meets one of the bones of the forearm (ulna).
During adolescence, the bones that form the elbow joint are still developing and are, therefore, more susceptible to injuries. During the throwing motion, stress is put on this part of the elbow. When too much stress is present (ie, from too much throwing) and when the joint is not able to recover properly (ie, when there is not enough rest time between periods of activity), the elbow can become painful and swollen. This results in the athlete being unable to throw with speed and accuracy at their normal volume. Pitcher's elbow can start as soreness, but if not diagnosed and treated early on, can progress to more serious injuries, such as tearing of the ligaments or fracture of the bone(s) of the joint.
How Does it Feel?
With pitcher's elbow, you may experience:
- Gradually worsening pain at the inside of your elbow when throwing a ball.
- Lingering soreness at the inside of your elbow following throwing activities.
- Swelling and tenderness around the inside area of the elbow area.
- Inability to throw the ball at your normal speed.
- Loss of grip strength.
- Loss of accuracy or distance when throwing.
- Muscle cramping in your forearm.
- Loss of motion of your elbow.
- Discomfort with daily activities that use your forearm muscles, like turning a doorknob or carrying a heavy object in front of you.
How Is It Diagnosed?
Diagnosis of pitcher's elbow begins with a thorough review of the athlete's medical history, including specific questions regarding athletic participation (sports played, frequency of practices and games, positions, types and numbers of pitches thrown). Your physical therapist will assess different measures, such as sensation, motion, strength, flexibility, tenderness, and swelling. The physical therapist will perform several tests specific to the elbow joint to examine the structures located there, and may ask you to briefly demonstrate the activities or positions that cause your pain. Depending on your symptoms, your physical therapist may even ask you to throw a baseball or softball to assess your throwing mechanics. The physical therapist will also ask you to give detailed information about your experience as a throwing athlete.
Because the shoulder and elbow are both involved in throwing, your physical therapist will likely examine your shoulder. Other nearby areas, such as your neck and upper back, will also be examined to determine whether they, too, might be contributing to your elbow condition.
If your physical therapist suspects there may be a more involved injury than overuse-related irritation (ie, if there is a recent significant loss of elbow motion or severe pain when the elbow is moved), the therapist may recommend a referral to an orthopedic physician for diagnostic imaging, such as ultrasound, x-ray, or MRI. All aspects of diagnosis, including subjective questioning, the clinical exam, and diagnostic imaging are important to determine the nature of your elbow injury.
How Can a Physical Therapist Help?
Once other conditions have been ruled out and pitcher’s elbow is diagnosed, your physical therapist will work with you to develop an individualized plan tailored to your specific elbow condition and your athletic goals. There are many physical therapy treatments that have been shown to be very effective in treating this condition. Your physical therapist may focus on:
Range of Motion. Because of the repetitive nature of throwing that causes the elbow to be irritated, it is often swollen and stiff, resulting in a loss of normal motion. You may also have abnormal motion of your throwing shoulder that is contributing to the way your elbow is acting during throwing. Your physical therapist will assess the motion of both of these joints compared to expected normal motion for your age and gender, as well as that of your other shoulder and elbow.
Strength Training. The muscles surrounding the shoulder and elbow as well as those of the upper back, work together to allow for normal, coordinated upper-body motion. This coordinated motion is especially important during throwing. Therefore, balancing the strength of all the upper-body muscles is crucial to making sure the shoulder and elbow joints move efficiently. Your physical therapist will teach you exercises to strengthen the muscles around the shoulder, so that each muscle is able to properly perform its job, and stresses are appropriately dispersed.
Manual Therapy.Physical therapists are trained in manual (hands-on) therapy. If needed, your physical therapist will gently move and mobilize your elbow and shoulder joint and surrounding muscles as needed to improve their motion, flexibility, and strength. These techniques can target areas that are difficult to treat on your own.
Pain Management.Your physical therapist may recommend therapeutic modalities, such as ice and heat to aid in pain management.
Functional Training.In the adolescent age group that typically suffers from pitcher’s elbow, an athlete is usually learning how to adapt their movements to a growing body. Poor coordination can place undue stress on the shoulder and elbow, and improper movements can, over time, cause pain in the body. Physical therapists are experts in assessing movement quality, and in training athletes to function at their best. Your physical therapist will point out and correct faulty movements in your throwing motion, so you are able to attain and maintain a pain-free elbow.
Education. The first step to addressing your elbow pain is rest. Your physical therapist will explain why this is so important, and develop a plan for your rehabilitation so you know when you will be able to safely return to your sport. Your physical therapist will also develop a personalized return-to-throwing progression of treatment and exercise, so you are able to move from your rest phase through a gradual reintegration of throwing activities to avoid another injury.
Can this Injury or Condition be Prevented?
Fortunately, there is much that can be done to prevent the cascade of events that lead to pitcher's elbow. Physical therapists help athletes and coaches focus on:
- Offering guidelines for throwing participation, explaining common causes of throwing-related injuries, and providing strategies for prevention.
- Educating athletes on the risks of playing through pain.
- Monitoring pitch counts, both during practice and game scenarios.
- Monitoring throwing participation (multiple sports, multiple leagues and teams, positions).
- Allowing adequate rest time for athletes to recover between throwing outings.
- Tracking a young athlete’s growth curves (height, weight, BMI).
- Developing an athlete-specific flexibility and strengthening routine that is done throughout the athletic season.
- Encouraging athletes to consult with a physical therapist if symptoms are worsening despite rest.
Real Life Experiences
Johnnie is a 13-year-old boy who has been playing baseball since he was in the T-ball leagues. As a young kid, he played every position, but he has always been best on the mound. Over the course of the last year, Johnnie has decided to stop playing soccer so he can focus on year-round baseball. He plays for his school team in the spring, and 2 travel leagues in the summer and fall seasons. His coaches have recognized him as one of the best pitchers on the team, so they spend extra time with him to work on his pitching mechanics during practice. His parents have invested in private pitching lessons, which he attends 2 times a week after his regular team practices. As a busy sixth grader, he is always trying to squeeze in homework between practices. And just like his dad, he is hitting his growth spurt at this age, earlier than most of his teammates.
Recently, Johnnie has been busy playing in many fall ball tournaments with his travel teams. Last week, coming off a long week of practice, he went back and forth between 2 tournaments, playing 7 games in 3 days. He pitched in 3 of these games, and played third base for the rest. When he got home from practice on Monday, he told his dad that his elbow was hurting. He said it had begun getting sore during 1 of his games that weekend, but he didn’t want to tell his coach since he knew they needed him to pitch against the best team in the league. Now he feels like his elbow is swollen.
His dad remembers hearing from another team parent that their son had to have surgery for an elbow injury, so he immediately calls his physical therapist.
Johnnie's physical therapist performs a thorough examination. He asks Johnnie about his recent baseball participation, and it soon becomes very clear that Johnnie has been overusing his throwing arm. The physical examination reveals that the inside of Johnnie’s elbow is very tender and swollen, and that he has lost motion and strength in that arm and in his shoulder.
Because Johnnie's arm is so tender, his physical therapist decides to refer him to an orthopedic surgeon for an x-ray. Fortunately, the results show there is no fracture, but that his arm bone is irritated.
Together, Johnnie, his physical therapist, father, and coach develop a treatment plan to help get him back on the mound. This begins with a period of rest where Johnnie does no throwing at all, but works regularly with his physical therapist on stretching, strengthening, balance, and coordination exercises, and on gently improving his throwing movements.
After about a month, when his elbow is less tender and he has met some of the goals set in therapy, his physical therapist and pitching coach meet with Johnnie to analyze his throw. As a team, they work with him to correct certain aspects of his throwing technique to decrease the chance of his developing another elbow or shoulder injury. They then develop a gradual reintegration plan for his return to baseball. They help Johnnie understand how important it is to be honest about his elbow pain, and to communicate with his coach if it starts to bother him again.
A month later, Johnnie is back pitching for the team. He has changed his routine to allow for adequate warm-up time before and after each practice. He also makes sure his dad and coaches are keeping track of how many pitches he throws at both practices and games, so he doesn't overdo it. He also decides to spend more time during the week working on his batting, so he can rest his pitching arm. At the end of the season, thanks to Johnnie's stellar (pain-free) pitching, his team wins the tournament championship!
What Kind of Physical Therapist Do I Need?
All physical therapists are prepared through education and clinical experience to treat a variety of conditions or injuries. You may want to consider:
- A physical therapist who is experienced in treating people with orthopedic or musculoskeletal injuries.
- A physical therapist who is a board-certified specialist or who has completed a residency in orthopedic or sports physical therapy, as they will have advanced knowledge, experience, and skills that apply to an athletic population.
You can find physical therapists that have these and other credentials by using Find a PT, the online tool built by the American Physical Therapy Association to help you search for physical therapists with specific clinical expertise in your geographic area.
General tips when you're looking for a physical therapist (or any other health care provider):
- Get recommendations from family and friends or from other health care providers.
- When you contact a physical therapy clinic for an appointment, ask about the physical therapists' experience in helping young athletes with elbow pain.
- During your first visit with the physical therapist, be prepared to describe your symptoms in as much detail as possible, and report activities that make your symptoms worse.
The American Physical Therapy Association (APTA) believes that consumers should have access to information that could help them make health care decisions, and also prepare them for their visit with their health care provider.
The following articles provide some of the best scientific evidence related to physical therapy treatment of little league elbow. The articles report recent research and give an overview of the standards of practice both in the United States and internationally. The article titles are linked either to a PubMed* abstract of the article or to free full text, so that you can read it or print out a copy to bring with you to your health care provider.
Shanley E, Thigpen C. Throwing injuries in the adolescent athlete. Int J Sports Phys Ther. 2013;8(5):630–640. Free Article.
Stein CJ, Micheli LJ. Overuse injuries in youth sports. Phys Sportsmed. 2010;38(2):102–108. Article Summary on PubMed.
Benjamin HJ, Briner WW Jr. Little league elbow. Clin J Sport Med. 2005;15(1):37–40. Article Summary on PubMed.
*PubMed is a free online resource developed by the National Center for Biotechnology Information (NCBI). PubMed contains millions of citations to biomedical literature, including citations in the National Library of Medicine's MEDLINE database.
Authored by Laura Stanley, PT, DPT, SCS. Reviewed by the MoveForwardPT.com editorial board.
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